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Evidence-Based Practice
Caring for a Patient Undergoing Total Knee Arthroplasty
Rebecca J. Parker
More than 500,000 total knee arthroplasty (TKA) surgeries were
performed in 2006 and the number is expected to continue to
increase (S. Kim, 2008). A background in evidence-based nurs-
ing care will assist any nurse assigned in caring for a postopera-
tive TKA patient. Strong pain assessment and reassessment skills
with an understanding of multimodal pain management bene-
fits pain control and patient recovery from TKA surgery. Safe
mobilization and therapy techniques that reflect evidence-based
practice will keep patients safe. Providing nursing interventions
that prevent complications from infections or thromboembolism
will reduce never events from occurring. This article will present
evidence for the care of a postoperative TKA patient.
T
otal knee arthroplasty (TKA) is a successful,
cost-effective, low-risk therapy that offers pain
relief and improves function for patients who do
not respond to nonsurgical treatment (Zhang
et al., 2008). DeFrances, Lucas, Buie, and Golosinski (2008)
report that 542,000 TKA surgeries were performed in
2006, almost double the number from 2000. Kim (2008)
estimates that 1.5 million primary TKA surgeries will be
performed in 2015. Total knee arthroplasty is performed
for patients who suffer joint failure from osteoarthritis,
rheumatoid arthritis, juvenile rheumatoid arthritis, or
osteonecrosis. Because of the expanding number of peo-
ple undergoing TKA surgery, the chances that a nurse
will provide postoperative care for a TKA patient is
highly likely. This article will examine evidence-based
practices of postoperative nursing care for TKA patients.
Pain Management
Aggressive postoperative pain management is required for
TKA patients (National Institute of Health, 2003). Strong
assessment of the patients pain is the first step toward inter-
vening to manage pain. Pain management interventions are
both pharmacologic and nonpharmacologic. Table 1 in-
cludes a synthesis of evidence related to pain management.
Pain management requires a skilled assessment, involve-
ment of patient, and the use of a multimodal approach
(Institute for Clinical Systems Improvement [ICSI], 2008;
Registered Nurses Association of Ontario [RNOA], 2002).
PAIN ASSESSMENT
The most reliable indicator of pain is through self-
report (ICSI, 2008). The nurse should educate the
4 Orthopaedic Nursing January/February 2011 Volume 30
Copyright 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
patient to report the amount of pain that is being expe-
rienced. The amount and type of pain should be as-
sessed using a valid and reliable pain scale such as the
Numeric Rating Scale or the Wong/Baker Facial Pain
Scale (ICSI, 2008; RNOA, 2002). Guidelines from the
ICSI (2008) support pain assessment upon admission,
at least once a shift, and at discharge. Additional re-
assessment should take place following any interven-
tion provided when the patients pain goal is not being
met. Assessing the patients current pain, pain goal, and
how the pain interferes with activities will help the
nurse develop a plan for managing pain (Akyol,
Karayurt, & Salmond, 2009).
PHARMACOLOGIC INTERVENTIONS
Acute pain is best managed using pharmacologic agents
(ICSI, 2008). Because of the severe pain experienced after
TKA, preemptive analgesia appears to be the best way to
begin pain management. Aiming to start the analgesic
process early and aggressively prevent pain, preemptive
analgesia is sometimes initiated even before the surgical
incision is made as anesthesiologists place epidural
catheters or continuous femoral infusions (CFI; Ginsberg,
2001). Chelly et al. (2001) found that patients who recov-
ered with a CFI had shorter lengths of stay, decreased
blood loss, and better postoperative pain control. It has
also been reported that patients with a CFI had better
pain management and improved immediate mobilization
than patients with an epidural catheter or patient-
controlled analgesic (Chelly et al., 2001). A retrospective
review study by Duellman, Gaffigan, Milbrandt, and Allan
(2009) found that preemptively administering oxycodone
and a selective COX-2 inhibitor resulted in reduced intra-
venous narcotics postoperatively, increased participation
in therapy, and decreased length of stay.
A multimodal approach to pain uses two or more drug
categories to relieve pain by different mechanism
(Duellman et al., 2009; Pasero & McCaffrey, 2007). The
most effective regimen uses around the clock oral opi-
oids, such as oxycodone, and an around-the-clock nons-
teroidal anti-inflammatory drug, such as celecoxib, with
immediate release opioid for breakthrough pain (Ginsberg,
Rebecca J. Parker, MSN, RN, CNL, ONC, Saint Marys Health Care,
Grand Rapids, Michigan.
The author has disclosed that she has no financial interests to any com-
mercial company related to this educational activity.
DOI:10.1097/NOR.0b013e3182057451
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TABLE 1. SUMMARY OF RESEARCH STUDIES REVIEWED

4:58 AM

First Author Design, Sample Size Level of Evidence Intervention Outcome Measures Results

Akyol Descriptive study, 120 TKR patients V Brief Pain Inventory Pain characteristics, contributing More information than pain severity
Page 5

Survey POD #4 factors, interference of pain is needed to properly assess pain,

with activities, satisfaction with pain affects activity
pain management after TKA
Duellman Retrospective review, 127 total joint III Multimodal preemptive Postoperative nausea, rehabilitation Multimodal preemptive medication
replacement patients medication with participation, length of stay led to decreased length of stay,
scheduled oxycodone decreased requirement of intra-
and COX-2 inhibitor venous morphine, decreased
nausea
Chelly Comparative study with three groups, III CFI for recovery Fever, wound infection, blood CFI had decreased postoperative
1. General anesthesia with PCA only loss and blood transfusions, bleeding, performed better on
2. Epidural analgesia level of pain, and morphine CPM, 90% reduction in serious
3. Continuous femoral infusion 92 consumption and associated complications, and 20% de-
patients adverse effects crease in LOS
Pellino Descriptive comparative and V Kit of nonpharmacologic Pain and anxiety in postoperative Kit used when received, decreased
correlational study, 65 subjects strategies orthopaedic patients opioid use and decreased anxiety

Orthopaedic Nursing

on POD 1 and 2 when kit received
Adie Systematic Review/Meta-Analysis of I Cryotherapy Blood loss, early ROM, transfusion Uncertain benefits, no support for
Random Controlled Trials, 11 requirements, pain, analgesia routine use
studies with 793 TKA patients use, swelling, LOS
Cepeda Systematic review of 51 studies, I Listening to music Effect of music on acute, chronic, Reduces pain intensity levels and
3,663 patients or cancer pain intensity, pain re- opioid requirements, magnitude
lief, and analgesic requirements of benefits is small

January/February 2011
Note. CFI  continuous femoral infusions; CPM  continuous passive motion; LOS  length of stay; POD  postoperative day; PCA  patient-controlled analgesic; ROM  range of motion; TKA  total

knee arthroplasty; TKR  knee replacement.

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NOR200171.qxd 1/7/11 4:58 AM Page 6
2001). Because postoperative pain is typically continuous
and severe, pain should be continuously treated with
around-the-clock medications for the first few days (Pasero
& McCaffrey, 2007; RNOA, 2002). The preferred method
for administration for postoperative pain medication is
oral because of convenience, cost, and patient tolerance
(Pasero & McCaffrey, 2007; RNOA, 2002). It is reported
that when pain is managed with a multimodal approach,
patients use less as needed basis (PRN) narcotic, increase
participation in rehabilitation, have less postoperative nau-
sea and vomiting, shorter lengths of stay, and decrease
need for skilled nursing at discharge (Duellman et al.,
2009). It is important to treat postoperative pain promptly,
especially breakthrough pain, because inadequate pain
control has been linked to slower mobilization of TKA pa-
tients and longer hospital stays (de Beer et al., 2005; RNOA,
2002). In addition to around-the-clock analgesics, patients
should have analgesics prior to walking, exercise, and sleep
to best control their pain (Akyol et al., 2009). For pain that
is difficult to control, consider a consult for pain manage-
ment from a pain management expert (RNOA, 2002). Pain
that is adequately controlled improves patient satisfaction
scores (Smith-Miller, Harlos, Roszell, & Bechtel, 2009).
NONPHARMACOLOGIC APPROACHES TO PAIN
Many nonanalgesic methods to managing pain have
been studied. Nonpharmacologic interventions include
cold application, relaxation, imagery, and music ther-
apy (RNOA, 2002). Muscle relaxation, music, massage,
and stress balls are other ways of managing pain that
have been reported in the literature (Pellino et al., 2005).
Pellino et al. (2005) offered TKA patients a kit that in-
cluded a cassette player with earphones, a tape of relax-
ing music, a tape with instructions for progressive mus-
cle relaxation, a plastic massager with instructions for
massage in nonsurgical areas, a stress ball, and a book-
let with information about how to use forms of relax-
ation. The study found that patients who received the
kit required less opioids and reported lower levels of
anxiety on postoperative day 2 (Pellino et al., 2005).
Music has been reported to have a positive impact on
pain. A review of the effects of music on pain found that
postoperative pain intensity was decreased by 0.5 units
(Cepeda, Carr, Lau, & Alvarez, 2006). Music is a safe,
low-cost intervention that nurses can provide to im-
prove the patient environment by distracting from post-
operative pain and increasing feelings of comfort
(Cepeda et al., 2006; McCaffrey, 2008). All nonpharma-
cologic interventions are based on individual preference
and should not be considered a substitute for medica-
tions but rather complimentary therapy.
Another method for pain control is cryotherapy or
the application of cold to the surgical site. In a system-
atic review and meta-analysis, Adie, Naylor, and Harris
(2009) found that patients who used cryotherapy saw a
significant reduction in pain on postoperative day 2
compared with those who did not use cryotherapy.
Although reduced pain was reported, this study found
that there was no significant decrease in the use of post-
operative narcotics with cold therapy. While cryother-
apy is a safe and economical way to attempt to manage
pain, its benefits are uncertain and may be more related
to pain wants (Adie et al., 2009).
6 Orthopaedic Nursing January/February 2011 Volume 30
Copyright 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
EDUCATION ABOUT PAIN MANAGEMENT
Patients who have had a TKA require education about
pain. The education should be done immediately post-
operatively and on an ongoing basis during the hospital-
ization. Standards from the ICSI (2008) recommend ed-
ucating on topics that include how long to expect pain,
the goal of pain management, preventing pain rather
than chasing the pain, treatments to manage pain,
how to ring the nurse for analgesic when needed, and
the plan for pain management, including the schedule
for medication administration. Instructing patients to
report unrelieved pain promptly is critical to effective
pain management (RNOA, 2002). Prior to discharge, in-
structions regarding pain management, analgesic uses,
and side effects and interactions of medications are re-
iterated (Akyol et al., 2009).
Patient Mobilization and Therapy
Postoperative TKA patients need the opportunity to mo-
bilize and ambulate. Postoperative complications are
prevented with ambulation. Physical therapy should be
an important part of the multidisciplinary team to teach
the patient how to use assistive devices and adhere to
any weight-bearing restrictions that are ordered. The
American Association of Orthopedic Surgeons (AAOS)
supports mobilization and ambulation by the first day
postoperative (Johanson et al., 2009). Although patients
will participate in therapy daily, they need the opportu-
nity to practice their new abilities with their nursing
caregivers (Radawiec, Howe, Gonzalez, Waters, &
Nelson, 2009). Evaluating each patient for fall risk to
confirm whether needs are met during the early mobi-
lization phase will translate to safe ambulation for the
patient (Radawiec et al., 2009).
The National Association of Orthopedic Nurses has
developed an algorithm to help healthcare professionals
determine the assistance needs of the patient on the basis
of weight-bearing status, safety risk, and ability of other
extremities (Radawiec et al., 2009). The algorithm will
lead the nurse to the safest option for ambulation and list
the number of caregivers needed to assist (Radawiec
et al., 2009). Mobilizing patients should be done in a safe
fashion following established guidelines to maintain
safety for all parties (Nelson & Baptiste, 2006). Many
evidence-based strategies, including patient lift devices,
establishing no lift zones, using patient lift teams, and
patient care ergonomic assessment protocols, have been
recommended by Nelson and Baptiste (2006). These
strategies will help promote patient safety, reduce falls,
and minimize employee injuries.
CONTINUOUS PASSIVE MOTION
One aspect of therapy for knee replacement patients is
use of continuous passive motion (CPM) machines that
are used to gently flex and extend the knee. They are used
to help the patient make progress by increasing range of
motion postoperatively. Following the initial setup of the
machine by the physical therapist, it is often the respon-
sibility of the bedside nurse to ensure the proper use.
However, the use of the machines has been questioned
as to their value. A review of eight studies by Grella
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(2008) found that the use of the CPM machine has no in-
fluence on short- and long-term knee extension, long-
term knee flexion, pain, complications such as infection,
deep vein thrombosis (DVT), and need for manipulation,
or length of stay when compared to rehabilitation with
early knee mobilization. Better outcomes with short-
term knee flexion have been seen when the CPM is ap-
plied immediately postoperatively at a high flexion arc
of motion, and for a significant amount of time each
day (Grella, 2008, p. 277). A study examining the use of
CPM in 65 patients undergoing computer-navigated
TKA found no benefit postoperatively of CPM use. There
was no statistically significant difference in flexion be-
tween the no-CPM group and the CPM group at 2 weeks,
6 weeks, and 3 months (Alkire & Swank, 2010).
Prevention of Thromboembolism
For patients undergoing an orthopaedic surgery, in-
cluding TKA, DVT and pulmonary embolism (PE) are
the most common life-threatening complications (Rice
& Walsh, 2001). Without prophylaxis, 40%60% of pa-
tients undergoing elective total hip replacement, total
knee replacement, and hip fracture repair would de-
velop a DVT within 7-14 days following surgery (Geerts
et al., 2008). The Centers for Medicare & Medicaid
Services (2010) named DVT following total joint re-
placement surgery a never event in 2008.
MECHANICAL AND CHEMICAL PROPHYLAXIS
Prophylaxis of DVT and PE is an important part of post-
operative care for the TKA patient. Guidelines from the
AAOS (Johanson et al., 2009) recommend mechanical
and chemical prophylaxis. Intermittent compression
devices should be applied to the TKA patients legs ei-
ther intraoperatively or immediately postoperatively.
All members of the multidisciplinary team should en-
sure that the compression devices are on the legs at all
times, even when the patient is out of bed. TKA patients
should mobilize as soon as it is possible. Patients should
be taught to perform dorsi and planterflexion of the an-
kles 10 to 20 times every half hour while awake. The
AAOS recommends that patients be in a chair several
times per day. Even patients with epidurals should be
encouraged and expected to be out of bed, and they can
begin to stand and ambulate when they are physically
able (Johanson et al., 2009). Chemical prophylaxis will
vary on the basis of physician preferences and patient
preoperative identified risk of PE and bleeding ten-
dency. The AAOS guidelines recommend the use of as-
pirin, low-molecular-weight heparin such as enoxa-
parin or dalteparin, synthetic pentasaccarides such as
fondaparinus, or warfarin (Johanson et al., 2009).
PATIENT EDUCATION
The AAOS guidelines recommend making sure that pa-
tients are educated on the signs and symptoms of DVT
and PE. Signs and symptoms of DVT are pain, swelling,
tenderness, redness, or skin discoloration that is local-
ized to one site. Signs and symptoms of PE include short-
ness of breath, rapid pulse, feelings of apprehension,
chest pain that is worse with deep breaths, coughing up
Orthopaedic Nursing
Copyright 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
blood, hypotension, and lightheadedness (Johanson
et al., 2009).
Elimination
Indwelling urinary catheters are sometimes used for pa-
tients undergoing TKA with operative bladder draining
as the indication (Madeo & Roodhouse, 2009).
Placement of an indwelling catheter increases the pa-
tients risk of developing the most common nosocomial
infection: a catheter-acquired urinary tract infection
(CAUTI) (Newman, 2007). A patient who develops CAUTI
has a longer length of stay and the cost to treat the infec-
tion increases the hospital bill (Madeo & Roodhouse,
2009). The Centers for Disease Control and Prevention
lists prolonged surgical duration as an indication for a
Foley catheter but states that it should be removed as
soon as possible and especially within 24 hr of insertion
(Gould, Umscheid, Agarwal, Kuntz, & Pegues, 2009).
NURSING ROLE
The Centers for Medicare & Medicaid Services includes
CAUTIs on the list of never events (Centers for
Medicare & Medicaid Services, 2010). The bedside nurse
is an essential participant in ensuring that the catheter is
maintained appropriately. Assess that the catheter bag is
positioned below the bladder to avoid reflux of urine into
the bladder and prevent kinks in the tubing that will pre-
vent the urine from flowing freely (Madeo & Roodhouse,
2009). The recommendations from the Centers for
Disease Control and Prevention include securing the
catheter to prevent movement (Gould et al., 2009).
Tubing is usually anchored or secured to the upper thigh
(Newman, 2007). The nurse should review the need for
catheterization and remove the indwelling catheter as
soon as possible after placement. Because duration of
the catheter is directly linked to the risk of bacteruria
and development of CAUTI, prompt removal is of up-
most importance (Madeo & Roodhouse, 2009).
The nursing care provided to a TKA patient will help
the patient recover safely and quickly. Managing pain,
mobilizing patients, following recommendations for
thromboembolism prophylaxis, and decreasing the risk
of CAUTI all contribute to safe postoperative care.
Using evidence-based practices to guide the nursing
care for TKA patients will help to ensure patient safety
and recovery.
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